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nspection Report Number <br /> Waste Tire Su & Inspection Report <br /> tL�3 State of California ,i n ,� � C_%CIWM8181(New 04104) Survey Form - Page 1 i I ' l <br /> California Integrated Waste Management Board - <br /> Part A- Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Inspection Type (Fill one)Site Suffix: ! J! 19: 1j� Q Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: � y( joq Q CHP Q CIWMB Q Complaint Q Educational Visit Other <br /> Business or Facility Name Inspected By Inspector <br /> Physical Address ' -- � Ll In f 1LJ <br /> ��i(yl.{ <br /> Street <br /> C4Inspection Date <br /> Code Time In Time Out J_ <br /> State ZIP Code L-E-] <br /> Business Rep Title � 0 AMFT 0 AM <br /> I_- O PM F <br /> _.1_._. . 0 PM <br /> Operational StatusTire Type Business Role Storage Type <br /> The Count(Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> r Q Active Q Passenger Q Generator Q Outdoor <br /> 0 : C) Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> 0 Q Inactive 0 Truck <br /> Longitude — Q Planned Q OTR Q End-Use Q Container <br /> Business Type (Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS Q Notice Of Violation Q Extension <br /> Q Q PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q ! Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> 0 ' 0 PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CIWMB <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CIWMB Enforcement <br /> Q Q 14 CCR§ 18461 -Manifest System Requirements for Waste Tire End-Use Facilities <br /> Q Q ! 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators Q In Compliance No Violations -� <br /> Q Q Other: § - <br /> Comments Fa— kly hr�5 "t o Caped D 39 1V, . 0_ Axi--Avg <br /> � -t ZCE0 T/°1�' l �f 9/Cv �S - 7 5 a S <br /> Inspection Form Included: Q; <br /> Comments Included: Q , <br /> ,Business Rep's Signature Phone Number Inspector's Signature Phone Number <br /> _.._. <br /> INSTRUCTIONS ON BACK Correct: Incorrect: X X;A it P L I E I I g 2 62081 <br /> White Copy:CIWMB Yellow Copy:Operator Pink Copy:LEA �� <br />